Demonstrators participate in a “reopen Delaware” rally in Dover, May 2020

Jonathan Ernst / Reuters

Since the novel coronavirus arrived in the United States, it has ravaged mainly urban communities. The greater New York City area alone accounts for approximately a quarter of all COVID-19 deaths in the country. Boston, Detroit, and New Orleans, among other cities, have been hammered as well. But until very recently, rural America was mostly spared. Ordered to stay at home, often without paychecks, rural Americans watched a coronavirus crisis unfurl in the news that seemed completely divorced from their own reality. Some joined “open up” protests, calling on state governments to lift stay-at-home orders and business restrictions. And with their communities still relatively undisturbed, it is little wonder that so many rural dwellers remain skeptical of the virus’s potential to upend their lives.

But the truth is that the pandemic in rural America is only just getting started. Testing has been limited or nonexistent in many sparsely populated regions, so the number of confirmed cases remains deceptively low. But a rash of recent outbreaks in rural prisons, nursing homes, and meatpacking plants has laid bare the vulnerability of America’s hinterlands and given an early indication of what the future will hold.

The pandemic in rural America will not be the same as the one that has overwhelmed cities across the nation. Less dense and less interconnected (without the sprawling public transit systems and international airports that serve cities), many of these regions are likely to experience outbreaks that are less dramatic than those in urban centers. But rural areas are woefully unprepared for even a slower-moving epidemic. Just as they have suffered factory closures and job losses over the last decade, these regions have been devastated by the loss of hospitals and medical personnel. One hundred and twenty-eight rural hospitals have closed since 2010, scattered across the country but concentrated in the South and Midwest. An additional 430 rural hospitals were described by one consulting firm in 2019—prior to the pandemic—as “near collapse.” And the loss of hospitals often means the loss of the medical providers these institutions employed, leaving fewer health professionals to treat rural residents, who tend to be in worse health overall than their urban counterparts.

Rural Americans are more likely to be obese, to smoke, and to have high blood pressure than Americans who live in cities. They have higher poverty rates, have lower rates of health insurance coverage, and are generally less physically active. All of these factors make them more likely to suffer serious complications if they are infected with the coronavirus.

NO LONGER AN URBAN SCOURGE

In many ways, Ohio’s experience with the novel coronavirus has been representative of the nation’s at large. Governor Mike DeWine ordered schools to close in March, when there were scarcely more than a dozen confirmed cases in the entire state. He closed down businesses shortly thereafter. Although the state still lacks critical testing capacity, the numbers of confirmed cases and deaths have risen relatively slowly compared with the numbers in neighboring states of similar size that implemented shutdowns later, such as Michigan and Pennsylvania.

As anticipated, cases were initially concentrated in urban areas such as Cleveland and Columbus. But that changed on April 20, when test results from the Marion Correctional Institute were released. With almost 2,100 cases among inmates and 300 among staff, rural Marion County, population 66,000, suddenly became Ohio’s coronavirus capital, eclipsing even Cleveland’s Cuyahoga County with a population 18 times greater. Rural Pickaway County, with a population of 55,000, is not far behind with 1,825 cases to date that stem from the county’s two state prisons. Per capita, infection rates in Marion (3,600 per 100,000 people) and Pickaway (3,300 per 100,000) Counties are higher than those in New York City (2,107 per 100,000).

In addition to prisons and nursing homes, meat-processing and packaging plants have emerged as major areas of concern in rural regions.

Nursing homes and long-term-care facilities have also become hotbeds of COVID-19 in rural areas, just as they have in urban ones. In Bluffton, Ohio, population 4,000, eight people have already died in a single nursing home and 21 more have tested positive. Allen County, where the nursing home is located, has only 135 confirmed cases to date, meaning that the facility accounts for 16 percent of the county’s cases. Nursing homes account for an even greater share of cases in other rural counties, including Putnam County (51 of 71 cases), Ashtabula County (56 of 160), and Geauga County (85 of 172). And those are only the reported cases. The Ohio Department of Health publishes data on confirmed cases in long-term-care facilities, but its figures are incomplete and updated only weekly, making the spread of COVID-19 in rural nursing homes difficult to track.

In addition to prisons and nursing homes, meat-processing and meat-packaging plants have emerged as major areas of concern in rural regions. In Salem, Ohio, the Fresh Mark meat-processing plant was closed for over a week after “several employees”—the number was not disclosed—were diagnosed with COVID-19; another plant in Springdale, Ohio, reported four cases but did not close. The situation for meat producers is even more dire in South Dakota, where almost half of the state’s confirmed cases are linked to a single Smithfield meat-processing plant in Sioux Falls. More than 800 Smithfield employees and 200 community members who had contact with employees have been diagnosed with COVID-19.

Immigrants make up the bulk of the 3,700 employees at the Sioux Falls facility, which was closed for two weeks but is now reopening. Some are undocumented and therefore unlikely to seek or obtain medical care. Others may have felt pressured to work even while ill, since calling in sick could have put their jobs at risk. These factors have helped the disease spread undetected in rural communities around meatpacking plants across the country. A recent investigation by USA Today found that rates of infection in counties containing the country’s 150 largest packing plants are higher than those in 75 percent of other U.S. counties. And owing to outbreaks, packing facilities in Ohio, Wisconsin, Iowa, Georgia, Minnesota, Missouri, and Pennsylvania have shut down or suspended work in recent weeks.

GOING IT ALONE

These known rural hot zones—prisons, nursing homes, and meatpacking plants—are working through the pandemic with minimal support from the federal government. Personal protective equipment (PPE) such as masks, gloves, and eyewear is in desperately short supply, in part because hospitals have understandably been given preferential access. Sourcing PPE has become absurdly difficult even for major health-care providers. As one physician recounted in The New England Journal of Medicine, Baystate Health of Springfield, Massachusetts, had to hire an underground broker to import masks and respirators from China, only to have the equipment nearly seized by the federal government upon arrival. Lower-priority institutions are having an even tougher time procuring supplies to protect their employees, patients, and inmates. Even meat inspectors employed by the U.S. Department of Agriculture have been told that they are on their own when it comes to PPE and instructed to purchase their own safety gear. At least one USDA inspector has died of COVID-19 and more than 100 have tested positive.

Lack of federal guidance on how to respond to outbreaks in all of these institutions has added to the problem. Meat processors have been allowed to reopen (or were never shut down), even while doing little to protect their workers. Some facilities have provided employees with masks and installed plastic sheeting between workstations, but workers remain in proximity to one another and use the same cafeterias and changing rooms. Rather than push processors to implement additional safety precautions (such as lowering the numbers of workers on lines, slowing line speeds to allow workers to spread out, and allowing workers additional time to wash their hands), the USDA has done the opposite. Last month, it allowed poultry-processing plants to increase their production speeds even though worker advocates warned that doing so would put employees’ health and safety at risk.

Prison and nursing home practices remain haphazard as well in the absence of federal guidelines. Judges have ordered the release of some vulnerable prisoners after other inmates died of COVID-19, but corrections officials have done little to ensure that those who have been exposed to the virus don’t carry it back to their families and communities. The Ohio Department of Rehabilitation and Correction, for instance, gave released prisoners written information about COVID-19 and asked them to self-quarantine for 14 days. But it did not provide accommodations for inmates to do so—many will have nowhere to go, except back to their families—or uniformly follow up on them to determine their infection status. Nursing homes have generally taken more precautions. Some have gone to extremes to control the spread of the virus, even considering moving some staff on campus to reduce exposure. Visitors have been disallowed in most locations, and cleaning procedures and PPE use by medical and nonmedical employees have improved. But with such a vulnerable population, it is difficult to contain the virus once it has entered a facility.

Lack of health insurance will mean that more people wait until the infection is potentially life-threatening before they report to an emergency room—if one is even accessible.

While rural communities are weeks or even months behind their urban counterparts on the pandemic curve, they may be about to see a sudden increase in COVID-19 cases and deaths. The outbreaks currently underway in high-risk facilities will inevitably spread outward, following workers, patients, and inmates to their homes and neighborhoods. Poorer health among rural Americans in general means there will likely be a higher percentage of serious cases in these regions. Lack of health insurance will mean that more people wait until the infection is potentially life-threatening before they report to an emergency room—if one is even accessible. And inability to test to identify early mild cases means that these communities won’t even know that the outbreak is increasing until hospitals start to be overwhelmed.

Rural outbreaks will be slower, steadier, and likely to continue for a longer period of time than those in urban areas. In some ways this may be advantageous—because there are fewer medical facilities, the curve in rural areas needs to be much flatter than in cities to avoid overwhelming local hospitals. But a flatter curve means a longer epidemic—potentially months of watching the infection spread slowly among friends and loved ones. This will be particularly crushing to first responders and other medical professionals. In small communities, doctors usually know friends or relatives of their patients—if not the patients themselves. Now, doctors will have to watch many of these people suffer or die from the illness. And with 60 percent of rural Americans living in areas with a shortage of mental health professionals, survivors may be left traumatized and without help to process their experiences.

Unfortunately, mounting political pressure on mainly Republican governors is likely to result in the premature lifting of social-distancing restrictions. Georgia reopened many business establishments on April 24 but gave minimal guidance on how to keep customers safe. Ohio Governor DeWine instituted a “gradual” reopening beginning May 1, allowing some manufacturing and office locations to open and medical procedures that had been placed on hold to go forward. Retail establishments are tentatively set to open up midmonth. Rural Americans who still haven’t seen many cases where they live may interpret these reopenings as carte blanche to return to “normal”—leading to a wave of new cases. And if areas are reopened before testing capacity increases, which is all but certain, these outbreaks may go undetected until they are too large to contain, necessitating another round of lockdowns. Ironically, in rural areas, where some social distancing occurs naturally, lockdowns may not even be the most efficient way to slow the spread of the disease. Face coverings may be a better option, but there has been some resistance to making them mandatory. (DeWine initially planned to require facemasks as part of Ohio’s reopening but reversed his stance after receiving backlash.) Regardless of the measures they take, rural areas are not yet out of the woods. The worst is still to come.

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TARA C. SMITH is Professor of Epidemiology at Kent State University in Ohio. Her research focuses on disease transmission in rural populations.